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Release Notes:
Data Element
Version 2010A1

Data Element Name: In-Hospital LDL-Cholesterol Test
Collected For: AMI-T1a, AMI-T2, , (CMS Optional Test Measure)
Definition:LDL-cholesterol (LDL-c) test performed during this hospital stay.

Suggested Data Collection Question:Was an LDL-cholesterol (LDL-c) test performed during this hospital stay?
Format:
Length:1
Type:Alphanumeric
Occurs:1
Allowable Values:

Y    (Yes)   LDL-c test was performed during this hospital stay.

N   (No)   LDL-c test was not performed during this hospital stay or unable to determine from medical record documentation.

Notes for Abstraction:
  • In the absence of explicit documentation that an LDL-c test was or was not performed during this hospital stay, it should be inferred that a test was done if:
    • There is documentation of an LDL-c value from a test performed during this hospital stay, or
    • There is physician/advanced practice nurse/physician assistant (physician/APN/PA) documentation which qualitatively describes the results of an LDL-c test performed during this hospital stay (e.g., “lipids elevated”), or
    • There is documentation that lipid testing was performed during this hospital stay.
  • Do not include an LDL-c value, LDL-c qualitative description, or lipid testing if it cannot be determined that the testing was actually done during this hospital stay.
    Examples:
    • “Impression: Elevated cholesterol” noted in consultation report done on day of admission
    • “Hypercholesterolemia” noted as discharge diagnosis in discharge summary, with no evidence that any lipid testing was done during the hospital stay
    • Physician/APN/PA writes “Labs within normal range except for cholesterol,” with no evidence that any lipid testing was done during the hospital stay.
  • Do not include lipid testing or qualitative descriptions of lipid test results if it can be determined that LDL-c measurement was not part of the lipid testing.
    Examples:
    • “Lipid profile done on day 2” per discharge summary, but the laboratory report lists only cholesterol and triglyceride values. Physician/APN/PA notes “Labs: elevated cholesterol,” but the laboratory report lists only a total cholesterol value
Suggested Data Sources:
  • Consultation notes
  • Emergency department record
  • History and physical
  • Laboratory report
  • Progress notes
  • Discharge summary
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
LDL-cholesterol (LDL-c)
  • Low den lipoprotein
  • Low density lipoprotein (LDL)

Qualitative description of LDL-c test results

  • Cholesterol level qualitatively described (e.g., low, normal, elevated, ↑)
  • Dyslipidemia (presence or absence)
  • Dyslipoproteinemia (presence or absence)
  • Hyperbetalipoproteinemia (presence or absence)
  • Hypercholesterolemia (presence or absence)
  • Hyperlipemia (presence or absence)
  • Hyperlipidemia (presence or absence)
  • Hyperlipoproteinemia (presence or absence)
  • LDL level qualitatively described (e.g., low, normal, elevated, above goal, below Target, ↑)
  • LDL-cholesterol (LDL-c) level qualitatively described (e.g., low, normal, elevated, ↑)
  • Lipid levels qualitatively described (e.g., low, normal, elevated, ↑)

Lipid testing

  • Cholesterol analysis
  • Cholesterol check ( ✓ )
  • Cholesterol panel
  • Cholesterol profile
  • Cholesterol testing
  • Fasting lipids
  • LDL: HDL
  • LDL: HDL ratio
  • Lipid analysis
  • Lipid check (✓)
  • Lipid panel
  • Lipid profile
  • Lipids
  • Lipoprotein analysis

LDL-cholesterol
VLDL (very low density lipoprotein)

Qualitative description of LDL-c test results
Alpha lipoproteinemia (presence or absence)

In-Hospital LDL-Cholesterol Test
Specifications Manual for Joint Commission National Quality Core Measures (2010A1)
Discharges 04-01-10 (2Q10) through 09-30-10 (3Q10)